Provider Demographics
NPI:1598050932
Name:GIBSON, RODERICK
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 COCKATOO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3137
Mailing Address - Country:US
Mailing Address - Phone:702-332-9398
Mailing Address - Fax:
Practice Address - Street 1:2420 COCKATOO DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-3137
Practice Address - Country:US
Practice Address - Phone:702-332-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty